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Disler R, Pascoe A, Chen XE, Lawson E, Cahyadi M, Paalendra A, Hickson H, Wright J, Phillips B, Subramaniam S, Glenister K, Philip J, Donesky D, Smallwood N. Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit. J Pain Symptom Manage 2024; 67:453-462. [PMID: 38365070 DOI: 10.1016/j.jpainsymman.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION/AIM Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. METHODS Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. RESULTS Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). CONCLUSIONS End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.
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Affiliation(s)
- Rebecca Disler
- Respiratory Research@Alfred, Department of Immunology and Pathology (R.D., A.Y.P., N.S.), Central Clinical School, Monash University, Melbourne, Australia; Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia.
| | - Amy Pascoe
- Respiratory Research@Alfred, Department of Immunology and Pathology (R.D., A.Y.P., N.S.), Central Clinical School, Monash University, Melbourne, Australia
| | | | - Emily Lawson
- Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia
| | | | | | - Helen Hickson
- Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia
| | - Julian Wright
- Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia; Goulburn Valley Health (J.W., S.S.), Shepparton, VIC, Australia
| | | | - Sivakumar Subramaniam
- Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia; Goulburn Valley Health (J.W., S.S.), Shepparton, VIC, Australia
| | - Kristen Glenister
- Department of Rural Health (R.D., E.L., H.H., J.W., S.S., K.G.), The University of Melbourne, Shepparton, VIC, Australia
| | - Jennifer Philip
- The University of Melbourne (J.P.), Parkville, VIC, Australia
| | - Doranne Donesky
- Department of Physiological Nursing (D.D.), University of California San Francisco, San Francisco, USA
| | - Natasha Smallwood
- Respiratory Research@Alfred, Department of Immunology and Pathology (R.D., A.Y.P., N.S.), Central Clinical School, Monash University, Melbourne, Australia; Department of Respiratory and Sleep Medicine (N.S.), The Alfred Hospital, Melbourne, Australia
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Ye S, Corbett C, Dennis ASM, Jape D, Patel H, Zentner D, Hopper I. Palliative Care Utilisation and Outcomes in Patients Admitted for Heart Failure in a Victorian Healthcare Service. Heart Lung Circ 2024:S1443-9506(24)00052-0. [PMID: 38461106 DOI: 10.1016/j.hlc.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/22/2023] [Accepted: 01/11/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Heart failure (HF) has high mortality and healthcare utilisation. It has a complex and unpredictable trajectory, which is often interpreted as a barrier to guideline recommended early integration of palliative care (PC). In particular, lack of referral criteria and misconceptions around PC affect inpatient specialist PC referrals. AIMS The main objective was to characterise the pattern and predictors of referral of HF patients to the specialist inpatient PC consultative service at our healthcare service. METHODS A retrospective, single-centre cohort study was performed on consecutive patients admitted across the hospital with HF over a 12-month period (July 2019-June 2020). Mortality data were checked against state death registry data. RESULTS The 502 patients admitted for HF were elderly (mean age 78±14 years), had high dependency (54% Australian-modified Karnofsky Performance Status (AKPS) 50-70, 29% AKPS 10-40), and high mortality (53% within median 32 months at death registry data linkage). Seven per cent (7%) were referred to inpatient specialist PC. AKPS 10-40 (62% of those referred vs 26% not referred, p<0.01), reliance on carers (65% vs 36%, p<0.01), and New York Heart Association (NYHA) class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but two or more admissions in the last 12 months for HF were not (16% vs 10%, p=0.21). Many PC domains, such as symptom burden, distress, and preferred care, were not adequately assessed. CONCLUSIONS Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients.
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Affiliation(s)
- Sylvia Ye
- Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
| | - Cathy Corbett
- Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia; Department of Palliative Care, Alfred Hospital, Melbourne, Vic, Australia
| | | | - Dylan Jape
- Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Hitesh Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Ingrid Hopper
- Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
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Fürst P, Schultz T, Strang P. Specialized Palliative Care for Patients with Chronic Heart Failure at End of Life: Transfers, Emergency Department Visits, and Hospital Deaths. J Palliat Med 2022. [PMID: 36576786 DOI: 10.1089/jpm.2022.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Specialized palliative care (SPC) may contribute to improved quality of life in patients with life-limiting chronic heart failure (CHF). This study examined SPC and possible differences in the care process regarding emergency department (ED) visits, transfers, and place of death for severely ill patients with CHF. Materials and Methods: This retrospective observational registry study used the health care consumption data from the Stockholm Regional Council. Logistic regression analyses of age, sex, palliative care, comorbidities, and socioeconomic status were performed. Results: Of the 4322 individuals who died of heart failure between 2015 and 2019 and did not reside in a nursing home, 24% received SPC. Receiving SPC was associated with a lower odds ratio (OR) of ED visits (OR 0.24, p < 0.0001), unplanned transfers (OR 0.39, p < 0.0001), and emergency hospital as a place of death (OR 0.10, p < 0.0001). Furthermore, a better socioeconomic situation, younger age, and fewer comorbidities were associated with a lower OR of ED visits and transfers (p < 0.0001 to p = 0.013 in different comparisons). Multiple comorbidities (p < 0.0002) and younger age (p < 0.0001) were associated with a higher OR of emergency hospitals as a place of death. Conclusion: Approximately one-quarter of patients who died of heart failure received SPC. Receipt of SPC was associated with a significantly reduced number of ED visits, transfers between health care services, and risk of dying in emergency hospitals.
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Affiliation(s)
- Per Fürst
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Torbjörn Schultz
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Martínez-Sellés M, Grodzicki T. Modification of Cardiovascular Drugs in Advanced Heart Failure: A Narrative Review. Front Cardiovasc Med 2022; 9:883669. [PMID: 35677686 PMCID: PMC9167993 DOI: 10.3389/fcvm.2022.883669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Advanced heart failure (HF) is a complex entity with a clinical course difficult to predict. However, most patients have a poor prognosis. This document addresses the modification of cardiovascular drugs in patients with advanced HF that are not candidates to heart transplantation or ventricular assist device and are in need of palliative care. The adjustment of cardiovascular drugs is frequently needed in these patients. The shift in emphasis from life-prolonging to symptomatic treatments should be a progressive one. We establish a series of recommendations with the aim of adjusting drugs in these patients, in order to adapt treatment to the needs and wishes of each patient. This is frequently a difficult process for patients and professionals, as drug discontinuing needs to balance treatment benefit with the psychological adaption to having a terminal illness. We encourage the use of validated assessment tools to assess prognosis and to use this information to take clinical decisions regarding drug withdrawal and therapeutic changes. The golden rule is to stop drugs that are harmful or non-essential and to continue the ones that provide symptomatic improvement.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
- *Correspondence: Manuel Martínez-Sellés
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland
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